About 1% to 3% of the United States population has treatment-resistant depression (TRD), a costly and disabling disorder. In recent clinical trials, deep brain stimulation (DBS) has been used on various neuroanatomic targets in the brain in an effort to treat TRD. Helen S. Mayberg, MD, and colleagues in Toronto published a report in 2005 which demonstrated encouraging results when using DBS in the subcallosal cingulate (SCC) matter, an area of the brain that has been dubbed “Area 25.” In this study, patients with TRD who had DBS experienced antidepressant response rates in excess of 50% when assessed 6 and 12 months after the procedure. “Although results were encour­aging, this initial pilot study was limited by being an open-label investigation,” says Dr. Mayberg. In an effort to garner more long-term efficacy and safety data on SCC DBS for TRD and extend experience with the procedure, Dr. Mayberg teamed up with Paul E. Holtzheimer, MD, and colleagues at Emory University and published a study in the February 2012 Archives of General Psychiatry involving 17 TRD patients who received the procedure. The analysis also aimed to address whether there was an antidepressant effect associated with sham SCC DBS and if the procedure was safe and effective in patients with treatment-resistant bipolar depression. (see also, Navigating Patients Through Depression) Analyzing the New Data on DBS In the study by Drs. Holtzheimer and Mayberg, participants received single-blind sham SCC DBS for 4 weeks, in which patients did not know if the DBS system was on or off. This was followed by active stimulation for 24 weeks. Patients were evaluated for up to 2...

Most patients who don’t disclose their feelings of depression to their primary care providers (PCPs) are primarily afraid they will be prescribed antidepressant medication, according to survey results published this month in the Annals of Family Medicine. Depression goes undiagnosed in one-fourth of primary care patients with major depressive disorder, or MDD, and the majority of those who seek help from a PCP do not receive appropriate treatment. In a follow-up telephone survey of more than 1,000 adults, researchers from the University of California asked patients why they would not discuss depressive symptoms with their PCP. Overall, the following reasons were given: 23% had an aversion to antidepressant medication. 16% felt that a PCP was an inappropriate source of care for emotional problems. 15% were afraid medical records would be seen by others, such as an employer. 13% didn’t want to be sent to a counselor or psychiatrist. 12% didn’t want to be considered a psychiatric patient. 9% were uncomfortable sharing private information with their doctor. 8% felt they might lose emotional control. 6% were uncertain about how to raise the topic. 5% concerned they would distract doctor from other health problems. 4% thought the doctor might think less of them; loss of esteem. According to the findings, patients who exhibited moderate or severe depressive symptoms were more likely to subscribe to those reasons. Medication aversion (28%), sharing of medical records (26%), losing emotional control (21%), and being referred to as a psychiatric patient (20%) were the highest among those patients. The investigators noted that depressed individuals may perceive their circumstances and competencies in a more negative light. Additionally,...

Previous research has shown that there appears to be disparate care among different racial and ethnic populations, especially in the treatment of coronary artery disease (CAD). Clinical studies also suggest that there are differences in the use of evidence-based medicine among these different racial and ethnic groups. According to published data, minorities with acute coronary syndromes are more likely to receive sub-standard care. It has been shown throughout the medical literature that racial and ethnic minorities often receive evidence-based treatments less frequently than Caucasians. Other studies show that minorities are often treated at facilities that are not as adept at adhering to composite performance measures. The Get With the Guidelines-CAD (GWTG-CAD) quality improvement program, provided by the American Heart Association and American Stroke Association, is designed to enhance hospital adherence to guidelines when managing CAD patients. The program employs a set of performance, quality, and reporting measures to track the quality of care at an institution, and it has been proven to improve adherence to evidence-based care of patients hospitalized with CAD. A part of the GWTG-CAD program is directed toward improving ethnic and racial disparities among CAD patients to the point where care is defect-free. The concept of defect-free care is a critical component in the GWTG-CAD program. At its core, defect-free care is intended to ensure that every patient receives all of the interventions for which they’re eligible. These interventions are also known as performance measures because their use in CAD patients is supported by well-grounded scientific evidence. Therefore, performance measures are well-suited for public reporting to compare hospitals and pay-for-performance initiatives. Quality Improvement Programs Work In...

The impact of major depressive disorder (MDD) on patients and their families is substantial. MDD adversely affects the patient as well as others, with the most serious complication of a major depressive episode being suicide. The disorder has also been associated with significant medical comorbidity. It can complicate recovery from other medical illnesses. Furthermore, MDD affects patients’ marital, parental, social, and vocational functioning. The disorder is unremitting in about 15% of patients and recurrent in another 35%. Compounding the problem is that treatment is often delayed. These factors highlight the need for changes in the delivery of mental health services to enhance timeliness and quality of care in MDD. With treatment, however, the prognosis associated with MDD is generally good. Most patients will respond to acute treatment, and continuation and maintenance therapy with acutely active treatments has been shown to lower the risk and severity of relapses into depression. Revisiting Previous Guidelines In 2010, the American Psychiatric Association (APA) released a new clinical practice guideline for the treatment of patients with MDD. This document (available online at www.psych.org/guidelines/mdd2010), the third since guidelines were originally created by the APA for MDD, revises a previous version that was published about a decade ago. “It includes new evidence-based recommendations on the use of antidepressant medications, depression-focused psychotherapies, and somatic treatments, such as electroconvulsive therapy,” says Alan J. Gelenberg, MD, who chaired the workgroup that developed the recommendations. “The guideline also addresses other topics, such as alternative and complementary treatments, treating depression during pregnancy, and strategies for treatment-resistant depression.” It took approximately 5 years to update the APA guidelines, Dr. Gelenberg says. “The update...